Treatment of enthesitis in Ankylosing Spondylitis


From having no proven therapies, with the possible exception of non-steroidal anti-inflammatory drugs which are of limited value, the treatment of the spinal polyenthesitis and associated osteitis (bone inflammation) that is responsible for AS has radically changed in the past 15 years. The anti-TNF agents which are a type of biological therapy have revolutionised disease management. Newer classes of biological therapy including targeting the Interleukin-23/Interleukin-17 axis are at an advanced stage of development. Likewise small molecules including PDE4 antagonists show efficacy for enthesitis. These are briefly summarised and a full therapy section will be developed in 2015

Summary of therapies

Non-steroidal anti-inflammatory drugs have a role in AS.

A role for sulphasalasine has not been proven but it may help pain.

Corticosteroids are not a viable long term therapy for controlling enthesitis linked to AS.

A role for methotrexate has not been proven

The Anti-TNF (tumour necrosis factor) therapies have transformed the management of the polyenthesitis associated with Ankylosing Spondylitis. The Anti-TNF therapies have also shown good efficacy for isolated resistant enthesitis in AS.

The Anti-IL12/23 therapies work for the polyenthesitis associated with Psoriatic Arthritis and also some preliminary studies show an effect in spinal disease in AS.

The anti-IL17 therapies also show a good effect in Ankylosing Spondylitis.

Apremilast is a Phosphodiesterase-4 (PDE4 inhibitor) that has been shown to work in the enthesitis associated with psoriatic arthritis.

Other molecules are also in development now that enthesitis is firmly on the therapeutic radar screens of the pharmaceutical industry.

A dedicated section on therapy will be created when the background information on enthesitis is more comprehensive.

Further reading

ARUK Website section on treatment for AS: What treatments are there for ankylosing spondylitis (AS)?